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Brazos Valley Vaccine HUB Volunteer Application
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Name
First Name
Last Name
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Email
Email
Please confirm we have permission to email you.
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Primary Address
Address
City
State/Province
Select
United States
Canada
United Kingdom
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Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic Of The
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte DIvoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic Peoples Republic Of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao Peoples Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, the Former Yugoslav Republic Of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States Of
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts And Nevis
Saint Lucia
Saint Martin
Saint Pierre And Miquelon
Saint Vincent And The Grenedines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard And Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Republic Of China
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela, Bolivarian Republic of
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Postal Code
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Primary Phone
+ (Select)
+1 (US/CA)
+44 (GB)
+20 (EG)
+211 (SS)
+212 (MA)
+213 (DZ)
+216 (TN)
+218 (LY)
+220 (GM)
+221 (SN)
+222 (MR)
+223 (ML)
+224 (GN)
+225 (CI)
+226 (BF)
+227 (NE)
+228 (TG)
+229 (BJ)
+230 (MU)
+231 (LR)
+232 (SL)
+233 (GH)
+234 (NG)
+235 (TD)
+236 (CF)
+237 (CM)
+238 (CV)
+239 (ST)
+240 (GQ)
+241 (GA)
+242 (CD)
+243 (CD)
+244 (AO)
+245 (GW)
+246 (DG)
+248 (SC)
+249 (SD)
+250 (RW)
+251 (ET)
+252 (SO)
+253 (DJ)
+254 (KE)
+255 (TZ)
+256 (UG)
+257 (BI)
+258 (MZ)
+260 (ZM)
+261 (MG)
+262 (FR)
+263 (ZW)
+264 (NA)
+265 (MW)
+266 (LS)
+267 (BW)
+268 (SZ)
+269 (KM)
+27 (ZA)
+290 (SH)
+247 (SH)
+291 (ER)
+297 (AW)
+298 (FO)
+299 (GL)
+30 (GR)
+31 (NL)
+32 (BE)
+33 (FR)
+34 (ES)
+350 (GI)
+351 (PT)
+352 (LU)
+353 (IE)
+354 (IS)
+355 (AL)
+356 (MT)
+357 (CY)
+358 (FI)
+359 (BG)
+36 (HU)
+370 (LT)
+371 (LV)
+372 (EE)
+373 (MD)
+374 (AM)
+375 (BY)
+376 (AD)
+377 (MC)
+378 (SM)
+380 (UA)
+381 (RS)
+382 (ME)
+385 (HR)
+386 (SI)
+387 (BA)
+389 (MK)
+39 (IT)
+40 (RO)
+41 (CH)
+420 (CZ)
+421 (SK)
+423 (LI)
+43 (AT)
+45 (DK)
+46 (SE)
+47 (NO)
+48 (PL)
+49 (DE)
+500 (FK)
+501 (BZ)
+502 (GT)
+503 (SV)
+504 (HN)
+505 (NI)
+506 (CR)
+507 (PA)
+508 (PM)
+509 (HT)
+51 (PE)
+52 (MX)
+53 (CU)
+54 (AR)
+55 (BR)
+56 (CL)
+57 (CO)
+58 (VE)
+590 (GP)
+591 (BO)
+592 (GY)
+593 (EC)
+594 (GF)
+595 (PY)
+596 (MQ)
+597 (SR)
+598 (UY)
+599 (BQ)
+599 (CW)
+60 (MY)
+61 (AU)
+62 (ID)
+63 (PH)
+64 (NZ)
+65 (SG)
+66 (TH)
+670 (TL)
+672 (NF)
+673 (BN)
+674 (NR)
+675 (PG)
+676 (TO)
+677 (SB)
+678 (VU)
+679 (FJ)
+680 (PW)
+681 (WF)
+682 (CK)
+683 (NU)
+685 (WS)
+686 (KI)
+687 (NC)
+688 (TV)
+689 (PF)
+690 (TK)
+691 (FM)
+692 (MH)
+7 (KZ)
+7 (RU)
+81 (JP)
+82 (KR)
+84 (VN)
+850 (KP)
+852 (HK)
+853 (MO)
+855 (KH)
+856 (LA)
+86 (CN)
+870 (IMAR)
+878 10 (VIS)
+880 (BD)
+881 6 (IRDM)
+881 7 (IRDM)
+881 8 (GSAT)
+881 9 (GSAT)
+882 13 (TV)
+882 16 (THU)
+882 32 (MCP)
+882 33 (ITU)
+882 34 (BC)
+883 5100 (VOX)
+883 5110 (BWCOM)
+883 5130 (SIP)
+886 (TW)
+888 (UN OCHA)
+90 (TR)
+91 (IN)
+92 (PK)
+93 (AF)
+94 (LK)
+95 (MM)
+960 (MV)
+961 (LB)
+962 (JO)
+963 (SY)
+964 (IQ)
+965 (KW)
+966 (SA)
+967 (YE)
+968 (OM)
+971 (AE)
+972 (IL)
+973 (BH)
+974 (QA)
+975 (BT)
+976 (MN)
+977 (NP)
+98 (IR)
+992 (TJ)
+993 (TM)
+994 (AZ)
+995 (GE)
+996 (KG)
+998 (UZ)
Dial Code
Phone Number
We need you to check here so we have your permission to call you.
I am happy to receive text (SMS) messages on this number.
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Birthdate
Month
Day
Year
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Organization Affiliation ("None" if not affiliated)
Please let us know if you are volunteering as a member of another organization
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Spanish Speaking
Spanish speakers are welcome to sign up for any available shift or to serve solely as interpreters.
Select
YES
NO
Other Languages Spoken
Please list all fluent languages spoken
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American Sign Language
Select
YES
NO
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Medical Professional
Medical professionals are able to serve as vaccinators, vaccinator assistants, and observers for post vaccination waiting period.
Select
YES
NO
Medical License # (Required for Vaccinators)
Vaccinators must have active medical license to administer the vaccine. • Licensed Vocational Nurse • Registered Nurse • Nurse Practitioner • Paramedic (excluding EMT basic) • Medication Aide • Pharmacist • Physician • Physician Assistant • D.D.S. Dentist
Medical License Expiration Date
Vaccinators must have active medical license to administer the vaccine.
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Willing to Volunteer in Person (PPE provided, following COVID Guidelines)
Select
YES
NO
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Computer Proficiency
Select
Highly Proficient
Somewhat Proficient
Not Proficient
Availability
Planned hour of operation are 7:00am-5:30 pm Monday-Friday, but this is subject to change.
Morning
Afternoon
Evening
Mon
Tue
Wed
Thu
Fri
Sat
Sun
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Feeding Partners-May we contact you to provide a meal for staff/volunteers
Volunteers will be offered bottled water during the shift. Lunch will be provided for volunteers working double shifts.
Select
YES
NO
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Received COVID Vaccine Dose 1
Vaccine will be available to volunteers, but is not guaranteed before your shift. Access to the vaccine for volunteers is based on availability of the vaccine.
Select
YES
NO
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Received COVID Vaccine Dose 2
Vaccine will be available to volunteers, but is not guaranteed before your shift. Access to the vaccine for volunteers is based on availability of the vaccine.
Select
YES
NO
COVID Recovered
Select
YES
NO
Other Services
Please let us know of any other service you would like to provide.
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Terms and Conditions
As a St. Joseph Volunteer working at the Brazos County Community COVID Vaccine HUB, you agree to:
• Self-screen at home prior to coming into any building. Refer to the signs & symptom checklist
• Wear your face covering at all times including when entering and exiting the building
• Wear eye protection when interacting with team members or patients
• Maintain social distancing (minimum of 6 feet) at all times
• Wear gloves if required for your assignment
• Practice hand hygiene by washing your hands and hand sanitizing frequently throughout your shift
• Not eat at your volunteer location as this would involve removing your face covering
• Clean your area at the end of your “shift” with antiseptic wipes
• No wearing of hats, sunglasses, or earbuds when volunteering
• No strong perfumes/artificial smells
• Nails must be clean and NOT ARTIFICIAL
Please read the following and sign indicating your understanding and agreement:
By signing below, I confirm that I have read, understand, and agree to the terms and conditions above.
This agreement does not constitute any employment agreement between me and CHI St. Joseph Health. The decision to volunteer with CHI St. Joseph Health to work in the Brazos County Community COVID Vaccine HUB is my own. I have not been forced or coerced to do so.
I agree.
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Terms and Conditions
CONFIDENTIAL INFORMATION
In fulfilling our duties, we see a wide range of confidential information. We treat information about our patients, residents, members and others we serve as confidential and proprietary information. This means that St Joseph Health does not share this information with the public and is careful to share with business partners only when they have a need to know the information. Confidential and proprietary information is maintained in different forms such as paper records, electronic records, films and verbal discussions. Sharing this information improperly can harm our mission, individuals in our care and our business partners. We have specific policies and procedures to maintain and protect the confidentiality of individuals we serve, employees and organizational information. For review of these policies, you may request St Joseph Health’s Privacy, Security and Confidentiality policies.
Information about Patients, Residents, Members or Others We Serve
Individuals we serve expect us to maintain the confidentiality and security of their health information. A St Joseph Health we not only follow the national and state privacy and confidentiality laws such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Breaking these laws may result in civil or criminal penalties of St Joseph Health and/or the responsible individuals.
The employees, affiliated physicians and health care partners of St Joseph are permitted to use or disclose protected health information (PHI) only to serve and care for our patients, residents, members and others in our care. We do not use, disclose, or discuss confidential information with others unless the patient, resident, member or other individual in our care authorizes the release of his/her information or we are required or authorized by law to release the information. St Joseph Health and the individuals who improperly use or disclose confidential information may face civil and/or criminal penalties for breaking these laws. In addition, employees may face disciplinary action up to and including termination.
Employee Information
We keep employee information confidential by following human resources policies and state and federal laws. Employee personal information includes wage and salary information, employment agreements, employment history and status, Social Security numbers, and financial and banking information.
I agree.
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Terms and Conditions
Waiver for Injuries/Damages
I understand that in consideration of being permitted to volunteer at CHI St. Joseph Health does hereby release and forever discharge the CHI St.
Joseph Health and any and all employees thereof from all liability which I, or my executors, administrators, or assigns, may, or can have by reason of my contracting any communicable disease or diseases as a result of such volunteer activities, and/or personal injuries or property loss incurred during such activities.
If you are injured while performing your duties and the injury is deemed as a result of your duties or environmental hazard, you will be taken to the Emergency Room to be assessed and treated by CHI St. Joseph Health. If you have insurance, they will file on it and cover any out of pocket expenses. If you become injured or are ill not as a result of your duties or an environmental hazard, you may still be taken to the Emergency Room (if required), but you will be responsible for all incurred charges.
***I understand that signing this form constitutes a legal signature confirming that I acknowledge and agree to the Waiver Statement.
I agree.
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Terms and Conditions
VACCINATIONS FOR VOLUNTEERS: While it is possible that a volunteer may be allowed to receive a vaccination from leftover amounts at the end of a shift on which they work, there is no guarantee or promise that this will happen. Vaccine supplies are strictly limited by state allocation. Please consider this if you are planning to travel to the hub from outside the Brazos Valley.
I agree.
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